Lung Isolation of Patients with Lung Transposition

A 51-year-old female patient with mirror-image dextrocardia and lung transposition (three lobes in the left lung and two lobes in the right) underwent thoracoscopic resection of an anterior mediastinal mass and partial right lung. Preoperative chest computed tomography revealed the take-off of the upper lobe of the left lung near the tracheal carina (fig. 1A). Flexible bronchoscopy confirmed intraoperatively that the left lung divided into three lobes (fig. 1B and Supplemental Digital Content video 1, https://links.lww.com/ALN/D566). Considering that the distal segment of the left-sided double-lumen tube may block the take-off of the upper lobe of the left lung and potentially cause severe hypoxemia during one-lung ventilation,1,2 the patient's lung isolation was achieved with a right-sided double-lumen tube (35 French) and intended surgery was completed uneventfully.Mirror-image dextrocardia, a rare congenital heart condition, often accompanies visceral transposition, such as lung transposition, presenting challenges in lung isolation. Careful consideration and planning are necessary for such a patient in thoracic surgery. A right-sided double-lumen tube is preferable for procedures not involving the right bronchus. If surgery involves the right bronchus, a right-sided double-lumen tube, together with a bronchial blocker, may be chosen to achieve lung isolation. However, intermittently pausing respiration and adjusting the double-lumen tube or blocker is vital for achieving and maintaining adequate lung isolation. Alternatively, a left-sided double-lumen tube could be considered, although it risks poor ventilation of the upper lobe of the left lung.1,2 If this is not possible, one can also insert the bronchial lumen of the right-sided double-lumen tube into the left main bronchus to achieve better ventilation of the upper lobe of the left lung.3In summary, lung isolation in thoracic surgery for patients with lung transposition demands meticulous planning and strategy from the anesthesia care team.The authors declare no competing interests.Video 1. Intraoperative flexible bronchoscopy confirmed three lobar bronchus in the left lung, https://links.lww.com/ALN/D566